Surgery

The are many surgical treatments for breast disease ranging from open surgical biopsies, lumpectomy, mastectomy and sentinel lymph node biopsy. The appropriate preoperative evaluation is paramount to making the correct surgical choice.

Surgery for Breast Cancer

Generally speaking there are two types of surgical treatments for breast cancer: lumpectomy or mastectomy. There are two goals related to breast cancer surgery: 1) remove/biopsy lymph nodes, and 2) remove the tumor with a clear surgical margin. A mastectomy removes ‘all’ of the breast tissue while with a lumpectomy (partial mastectomy) only the mass/lesion is removed .

Lumpectomy which typically will include adjuvant radiation therapy has been found equivalent to mastectomy in terms of long term survival. The procedure involved the removal of the abnormal tissue only. The need for a negative/clear peripheral margin is critical. Adjuvant radiation therapy is necessary in most cases where lumpectomy is the chosen surgical treatment. Radiation is given to the breast to address any potential microscopic disease is ‘left behind’. Local recurrence rates (the chance of the same cancer reoccurring in the breast) with lumpectomy AND radiation therapy is approximately 2-3% ; whereas the recurrence rate without radiation therapy is approximately 30%.

Utilizing surgical techniques (Oncoplastic), the defect created by a partial mastectomy can be repaired. Following lumpectomy and radiation the appearance of the breast should be relatively the same as preoperatively.

Mastectomy involves removal of all of the breast tissue. In reality however, there is a small amount of microscopic breast tissue that remains. Thus, the local recurrence rate (the chance of the same cancer reoccurring in the breast) is approximately 2-3%. This is as low a local recurrence rate that can be achieved. Most importantly however, the overall survival is no different than a lumpectomy.

There are different types of mastectomies: skin sparing mastectomies remove all the breast tissue, including the nipple and areola, leaving behind most, if not all of the native skin. These procedures are typically done in conjunction with reconstruction. Nipple/areolar reconstruction can be performed by a plastic surgeon, at a later date; nipple sparing mastectomies remove all of the breast tissue; the nipple/areolar complex is not removed and remains in place; areolar sparing mastectomies remove all of the breast tissue, including the nipple; the areola remains. The nipple is reconstructed by a plastic surgeon, at a later date.

The indications, risks, and benefits of each mastectomy option differs slightly, as does the indication to consider each.

Reconstruction. Immediate plastic surgical reconstruction, under most circumstances, can be performed at the same setting, if mastectomy chosen as the surgical approach. There are times, however, when a delayed reconstruction might be preferred or recommended. There are a number of different types of breast reconstruction, including placement of an implant, tissue transfer (TRAM Flap, etc) and free flaps (DIEP Flap, etc.). Reconstruction is typically initiated during the initial surgical intervention, but, can also be performed at a later date.

Sentinel Lymph Node Biopsy

In the past, to ‘stage’ breast cancer, a complete axillary lymph node dissection was performed. During this procedure, approximately 15-20 lymph nodes were removed, and, assess histologically (under a microscope). This allowed doctors to assess whether or not cancer cells had begun to spread. In women with clinically negative lymph nodes (those that were not abnormal to physical exam or x-rays), where less likely to have disease in the lymph nodes, so, ultimately negative or clear lymph nodes were removed, but, provided no benefit to the patient, only potential side effects. Thus, it was determined that a better mechanism must be found to evaluate lymph nodes for spread of disease.

The sentinel lymph node is the first lymph node(s) that would receive spread of disease, IF, the disease had begun the process of spreading. This lymph node was first utilized in patients who had skin cancer (melenoma); because in these patients the route that cancer spreads is very unpredictable.

To identify this particular lymph node (at times there may be more than one), the breast is injected with a radiotracer and/or a blue dye. These tracers are absorbed by the breast tissue, and, enter the lymphatic system of the breast, ultimately finding their way to the sentinel lymph node. A special probe is utilized intraoperatively, to identify which lymph nodes have the tracer, and, thus the sentinel lymph node(s). By analyzing these nodes, physicians can determine if cancer has begun the process of spreading.

The dye/tracer will drain to the lymph nodes, but, this does NOT mean that the cancer has spread. It is only by analyzing these nodes histologically, that this can be determined.

Research has validated the use of sentinel lymph node biopsy in staging breast cancer. In a trial involving 5,611 women with breast cancer and no clinical signs of axillary metastasis, researchers from the National Surgical Adjuvant Breast and Bowel Project (NSABP), which is a National Cancer Institute (NCI) clinical trials cooperative group, randomly assigned participants to receive SLNB alone or SLNB plus an axillary lymph node dissection (ALND).

The researchers found no differences in overall and disease free survival between the two groups of women. Based on these results, it was concluded that ALND might not be necessary for women with clinically negative axillary lymph nodes and a negative SLNB whose breast cancer is treated with surgery, adjuvant systemic therapy, and external-beam radiation therapy.

Other Types of Breast Surgeries

Breast biopsies are sometimes required to make a definitive diagnosis. If the lesion of concern is too small to appreciate by ‘feel’, a needle localization may be necessary. Needle localization, is done in the Breast Imaging Department. A mammogram or ultrasound (sometimes an MRI) is used to identify the lesion of concern, and, then to guide a wire, placed next to (adjacent) to this area of concern. This localizing wire, will assist surgically, in identifying the area of concern.

Subareolar dissection is a procedure that is sometimes performed in women who have unexplained nipple discharge. This is a procedure, whereby, the affected (draining) duct is isolated and a portion removed. Similar to a breast biopsy, the procedure sometimes requires a preoperative localization. Although most nipple discharge is from a benign (noncancerous) etiology, biopsy/subareolar dissection is at times required.

Vascular Access Catheters/Ports

Many times, when chemotherapy is necessary, a port or vascular access catheter is placed. The catheter is placed in the operating room or Interventional Radiology. The port is attached to a catheter, which is placed in the venous system, just above the heart. An x-ray will be done to assure proper port placement.

How will the implant be accessed? A catheter is placed, through the skin, into the port (which has a rubber top). The medication can then be placed into the port, which will then feed into the catheter, and , via the catheter, into the patients venous system.

Will the port require care? No particular care is required, aside from normal good hygiene.

Once chemotherapy has been completed, the port can be removed, during a relatively short, outpatient, procedure.

“My husband and I want to thank you for your kindness during this difficult diagnosis of breast cancer. Even though this has been a slow process, I appreciate your professionalism and expertise in not taking any short cuts. I will be looking forward to working with you and your staff to get me through this (and be cured)! Any man can be a physician - but it takes someone special to be a Doctor. Thank you!”

-Wendy

“I first want to say thank you to all of you for making this bad experience a little brighter. You were all so nice, informative and made this journey a lot easier. Your office staff is awesome. Dr. Brown - I can’t thank you enough for your great work, bedside manner and you recommended great doctors to me. Thank you!”

-Suzanne

“I am not a ‘doctor person’ but you have made me feel so comfortable that you have taken the fear out of every visit. I am blessed to have you as my breast care giver.”

-Pat

“Over the past 12 years you have been such a blessing in our lives. Please know that our thanks could not be more heartfelt or sincere. We appreciate everything you have done in the past and are extremely grateful for the continuing medical care. You are an amazing person. Thank you again and again and again…”

-Mike & Sharon

“Through my misfortune of having cancer, I consider myself very fortunate to have you for my doctor. With you knowledge, kindness and sense of humor there was never a doubt in my mind that I was in very good hands. I cannot say enough great things about Sandy and your staff. I never had to worry about anything but showing up for the next appointment or procedure. Thanks for handling the details! Also, thank you for referring me to equally great doctors. You have touched my life and I am forever grateful!”

-Kim

"Because of your and your expertise and careing, I am here enjoying a much better year. Thank you again for the being the best "Doc" ever! Me and Bob won't rub in how much we are enjoying our two months in Florida :). See you soon!"

-Bob and Patti

"We consider you very valuable for all you do for us. Your planning with the best teams ... you are captain of the ship!"

-Rosemary W

"You obviously really care about your patients and follow up is really appreciated!"

-Linda K

"It is rare one finds a doctor so wholly suited to the medical profession: your hands saved my life and your kindness gave me the confidence to let them. God bless you."

-Martha R

"Thanks is such a little word but it has brought more real appreciation than a hundred words could say. Thanks most of all for just being you!"

-Aldona D

Thank you Dr. Brown and Sandy for the care and concern you have shown me, from the moment I walked in your office I was confident everything would be fine. My biopsy surgery..... I saw Dr. Brown he had a smile of encouragement on his face although I was extremely nervous and concerned I had to relax when I saw Dr. Brown. Although my process is just getting started I will continue to trust in the God given talents of my surgeon. My best to you and your staff!

-RC

"Words cannot begin to describe how comfortable and relaxed you made me feel during this time of my life. Your are an extremely passionate and caring doctor. I am deeply grateful for you! Thanks you."

-JD

"I am so grateful to have been referred to you and the Comprehensive Breast Care practice when I found out I needed cancer treatment. I can't say enough - to anyone I meet - about the amazing,, considerate, empathetic care I got as your patient! You have gone above and beyond to perfect the process of helping patients get through breast cancer - that is second to none! You are an amazing doctor and surgeon - but it is through your ability to reassure, encourage, empathize and TEACH that you shine so bright."

-LZ

"After reading the National Cancer Institutes study regarding Oncotype DX, I felt compelled to once again 'thank you' for having the inside to utilize this test for me over 21/2 years ago. When the result was right in the middle and I was ver hesitant to undergo chemo, you went a step further and ordered a Mammaprint the happily indicated that chemo would not be needed.
I so appreciate your intellect, compassion and professionalism and once again want to offer you my heartfelt thank you for all you do!!"

-JW

Thank you so much for going "above and beyond" for me. Your skill as a surgeon saved my life. Your compassion saved my spirit during one of the most frightening times of my life.

-SK

Dr. Brown, thank you so very much for all that you've done to help me. I can't imagine having to go through this without such kind support. Now I know why my friends were so happy to hear that you were my surgeon Dr. Brown! May God bless you and yours.

-HS

We walked into your office with very little information or explanation ... we were scared and nervous to say the least. As soon as Dr. Gold entered the room and started speaking, the fears and anxiety started to fade. Dr. Gold is not only extremely knowledgeable in her field of expertise, but her interaction with us was very professional yet very personal. Dr. Gold spent a lot of time with us explaining the cancer, options for treatment, and outlined the next steps. We have never had such a good experience with any doctor!

-VB

As a second time patient I really want to thank you all for truly making me feel at ease and cared for. It is good to be appreciated and I do appreciate you and your team Dr. Gold Thank you!

-TK

I can't thank you enough Dr. Brown and Sandy for being so kind and compassionate. I had bilateral breast CA eight years ago. It was so hard to accept and just a few days after my lumpectomy, my father died which added to the sadness and stress of the cancer. It was such a terrible time in my life but thanks to Dr. Brown and Sandy, I got through it and did very well. Without their kind and caring approach and their sense of humor and also the willingness to arrange everything for me, I wouldn't have been able to get through i

-WC

Good doctors like you replace the fear of illness with trust in recovery. Thanks.

-FJ

Thank you just doesn't seem like enough to say to you and your staff for helping me through this difficult period in my life. I am truly grateful for your surgical skills and all the kind and encouraging words along the way. With my heartfel thank you for everything.

-JK

Thank you for the excellent care and service you have provided. It is never easy for anybody to find out that they have cancer but you helped me navigate through it. You accomodated my time, made appoointments for me, and gave me advice and knowledge on the next steps that made this journey much easier for me. The level of care you are providing makes a difference, keep it up, patients really appreciate it!

-BM

Thank you for taking the time to see me for an appointment. You are an extraordinary doctor and person. I appreciate the work of your staff. I am confident to leave my health in your good hands. Thank you for your time, compassion and professionalism.

-JM

Dr. Brown. Words cannot convey how grateful I am to have had you as my surgeon. From the moment I met you, though I was frightened and fearful, I felt comfortable and confident in your ability. You have exactly what I needed: the perfect blend of knowledge, compassion and humor - each applied at the right time and in the right amount. You were patient in answering all my questions both before and after surgery. On the day of surgery your calm manner and gentle humor helped calm me.

-PL

Dr. Brown. Thank you for everything you do! I honor you for saving our lives in these hard times. Your kindness is appreciated more than words can say.